Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Tuesday, May 20, 2008

Newsweek has a lengthy story on bipolar children. Well, really, it's about one child and his family. After reading it, there is no doubt that something is very much wrong with the child (Max) profiled in the story. The story is interesting in how it portrays bipolar disorder in kids. A few things I noticed follow.

1. Max's problems are described by the journalist as "incurable" and as "a life sentence." It is true that the kid is likely in for a life of trouble. But stating that such difficulties are a certainty for the rest of his life? That's a little too certain and it's not based on any evidence. Show me one study that indicates that 100% of children like Max will always have a high level of psychological difficulties and essentially be unable to function independently.

2. The biology of child bipolar disorder is discussed as if we have a very firm grasp on the concept, then one major limitation is noted quite briefly.

Scientists now know that bipolar children have too much activity in a part of the brain called the amygdala, which regulates emotions, and not enough in the prefrontal cortex, the seat of rational thought. "They get so emotional that they can't think," says Mani Pavuluri, a child psychiatrist at the University of Illinois at Chicago. More than the rest of us, a bipolar child perceives the world as a dramatic and dangerous place. If he is shown a picture of a neutral face, he may see it as angry. Show him one that really is angry, and his prefrontal cortex will shut down while his amygdala lights up like a firecracker. The typical result: a fury that feeds on itself. Neurological research has its limits, though, and bipolar disorder still cannot be identified based on brain scans.

So dedicate space to how far science has progressed then quickly note that, by the way, these biological findings are useless in making a diagnosis. That's a rather important limitation.

3. How are all of the medications working out for Max?

By 7½, Max was on so many different drugs that Frazier and his parents could no longer tell if they were helping or hurting him. He was suffering from tics, blinking his eyes, clearing his throat and "pulling his clothes like he wanted to get out of his skin," says Richie. In February 2005, under Frazier's supervision, the Blakes took Max off all his meds. With the chemicals out of his system, Max was not the same child he had been at 2. He was worse. Bipolar disorder often gets more serious with age. The brain also reacts to some drugs by remodeling itself, and its dopamine receptors end up naked and sensitive. When the drugs are removed, it's a shock. Off his meds, Max became delusional and paranoid. He imagined Amy was poisoning him and refused to eat anything she cooked. He talked about death constantly and slept little more than two hours a night. Within a month Frazier had put him back on medication, but with a caveat: she wanted to place him in a short-term bed in a child psych ward.

But wait, there's more...

At 10, he has been on 38 different psychoactive drugs. The meds have serious side effects. They have made Max gain weight, and because he's still growing, they frequently need to be changed. The Blakes are aware that many people think their child—any child—should not be on so many drugs. They aren't always happy about it either. But to some degree, they have made their peace with medication.

Yes, you read that correctly -- he's been on thirty-eight psychiatric meds and he's 10 years old. Gee, I wonder if such a heavy regimen of medication is healthy for the developing brain?

4. More on "the bipolar brain"

The bipolar brain tries to compensate for its weak prefrontal cortex by roping in other areas to help; these areas may now become dysfunctional, too. Child psychiatrists thus face an enormous practical challenge: they often can't treat one disorder without affecting another one. "It's like a balloon where you push on one side and the other side pops out," says Wozniak, the MGH psychiatrist who helped define childhood bipolar disorder. With kids like Max, she adds, parents often have to settle for "just having one part of the symptoms reduced."

Um, okay. The bipolar brain "ropes in" other, unspecified brain areas to help the weakling prefrontal cortex and then these areas become dysfunctional too. I'm not a neuroscientist, but I think this explanation is strange at best.

5. Get ready for MANIA

During a recent appointment at Frazier's office, he went into full-fledged mania. Laughing wildly, he rolled on the floor, then crawled over to his parents and grabbed an empty medication bottle, yelling, "Drugs! I've got drugs! It's child safety!" Richie grabbed it back, Max screamed, Richie threw the bottle across the room, as if playing fetch. Max squealed and dove for it, then began to sing into the neck of the bottle: "Booorn to be wiiiiild …" Amy rolled her eyes: "Two kids." And then: "It's hard not to laugh."

It was. And it was hard to look at Max, who has borne so much, and remember that the grin on his face was not a sign of childish goofiness but a symptom of an illness.

Laughing, yelling, rolling on the floor -- it's definitely a manic episode. They probably should have given him a fat injection of Risperdal Consta to calm him down. Oh, and smiling is a symptom of mania as well. Gosh, I am learning sooooooooooo much about bipolar disorder from this article. I can't wait until the DSM-V comes out, at which point we'll discover that we're all bipolar.

Sarcasm aside for a moment, I am not making light of the situation faced by Max and his family. I can understand the sense of desperation felt by the parents and, to some extent, by the treating physicians. The story just rubbed me the wrong way a few times. The story's author was able to find some psychiatrists who were on the bipolar bandwagon, but she was somehow just not quite able to track down the unnamed critics of the bipolar child paradigm that she briefly mentioned in her story. So the bipolar advocates are given names and are quoted, while the nameless critics are essentially a footnote in her story.

4 comments:

Have you seen the accompanying video? I know many people can't bring themselves to watch it but I did and boy, is it sad. But I agree with your point on the manic aspect. In the beginning of the video, Max rambles for a bit and laughs. His parents nod matter-of-factly with a knowing smile and say, "That's the mania."

Wow. I ramble quite a bit myself like that kid. (Yes, I'm weird. 26-year-old females should not be laughing when someone says "duty.") I just considered it an odd part of my personality. I suppose I'm manic when I'm not depressed.

Unless Max wasn't manic at that moment, but just a normal kid. I can only imagine that Max MIGHT have had the potential to be all right had he not been on all those meds. You have to admit, because of all those meds, the kid will effectively screwed mentally to some degree.

On the last IACAPAP-congress (May 2008, Istanbul), I attended a lecture about childhood bipolar, mostly out of curiosity. It seems to be a rather common diagnosis in the US, but in the 15 years that I'm working as a child psychiatrist I saw 1 (one) child under 12 that perhaps might be diagnosed as bipolar - and the experience of the rest of my European collegues is similar.

That speaker in Istanbul pointed out all the differences that are said to exist between childhood and adolescent bipolar (extremely rapid cycling, irritability instead of mania, not reactive to Lithium, grown-up children with childhood bipolar don't present with adult bipolar and so on...)So he concluded: 'If a duck doesn't look like a duck, isn't waggling like a duck, doesn't quack like a duck... would it be possible that it isn't a duck at all?

And another speaker (I should look up their names) gave a very interesting lecture about the very rare 'childhood bipolar', and the probably much more common disorder that might be called 'severe mood dysregulation disorder'.

When I take what I've been reading about attachment theory, I have to question why the role of the parents in the emotional development of these children isn't examined more closely. These medications have become autopilot for a generation of people now, and why? I guess it's hard to get a patent on a variant of cognitive behavioral therapy.

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About Me

I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...